Just A Spoonful of…
Helps the Medicine go
Down!
Rosalie Favreau CCLS Certified Child Life Specialist
Dawn Kidder CCLS Certified Child Life Specialist
Child Life Department
Children’s Hospital
Health Sciences Centre
Winnipeg
Just a spoonful of sugar may help the
medicine go down for some children, but when
it comes to the child who simply states, “ I can’t
swallow pills!”, You Need a Plan!
Presentation Overview
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Planning for Success: Assessment, Plan,
Intervention, Evaluation
Common Barriers to Pill Swallowing
Traditional Behaviour Modification
Review Two Evidenced Based Practices
to Successful Pill Swallowing
Teaching Video (6 mins)
Demonstration
References and Discussion
Encouraging Mastery with Pill
Swallowing
GOAL: To teach a child to swallow pills. In order
to achieve this goal, the clinician must have a
strategy based on an individual assessment, a
concrete plan, an intervention and be able to
evaluate the outcome.
TB Medications
Assessment:

Understand the common barriers to pill
swallowing including: physical issues, fear of
choking, bad taste, size, loss of control and
power (compliance), pill placement, taking too
much water.
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Individually assess the patient and the
patient’s family including: age, development,
previous experience with illness and
hospitalization, relationship with their health care
team, understanding of their illness and
treatment, side effects of treatment , personal
barriers, and family dynamics.
Understanding illness and
treatment
Rehearse using a
personalized muslin
doll, patient puppet,
photographs,
supportive dialogue
and/or written
information.
Plan:
 Choose
from evidence based practices or
modify a program that you as a clinician are
comfortable with.
 Use your clinical skills: adopt a playful and
supportive attitude that will encourage the
child’s sense of comfort, choice, and control.
 Practice family centered care. Involve and
guide the parent/caregiver who will be
supporting their child in “doing their
homework”. Practice is the key to success.
Intervention:
 Implementation
of your chosen program
 Ongoing assessment of how’s it’s working
and problem solving when necessary
Evaluation:
Is your program working?
Do you need to modify your
approach?
Ultimately the goal is achieving
MASTERY with pill swallowing
within a determined time frame.
Most traditional approaches to pill swallowing
rely on Behaviour Modification
BARRIERS
STRATEGIES
LEARNING
Taste
Crushing or
cutting
Growing
autonomy
Size
Alternative
administration
Learning by
doing
Feelings
Taking with food Repetition/
perseverance
Bodily
discomfort
Taking with or
without water
Avoidance
Control
The ABC’S of Behaviour
Modification
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Problems are defined as behaviours that are
measureable. Allows for accurate charting and
documentation.
Treatment alters patient’s environment to increase
functioning. Program increases a patient’s ability to
be normal.
Techniques are based in everyday life. Teaching
needs to be concrete and easy to understand.
Techniques are based on principles of learning.
Program shows patients that swallowing pills is a
learned behaviour.
Demonstration of techniques cause change. The
skills need to be shown to the patient to promote
learning.
Martin and Pear 2007
Positive Reinforcement, Shaping
and Modeling Definitions
 Positive Reinforcement supporting the
desired behaviour. Example: praise after both
successful and unsuccessful pill swallows
 Shaping reinforcing consecutive, increasingly
accurate behaviours. Example: Increasing “pill”
size slowly to achieve desired goal
 Modeling demonstrating the desired
behaviour or skill. Example: showing the patient
correct pill placement for success
Martin and Pear 2007
Positive reinforcement and appropriate
incentives:
Praise, sticker charts, prizes that appeal to
the individual, etc.
Evidenced Based Practices
Breaking Down the Barriers of Pill
Swallowing Through Behaviour Modification
“You CAN Do It” Pill Swallowing Program
A study was initiated after a large number
of cardiac transplant patients were “noncompliant” with their anti-rejection
medications. The patients ranged from 4
-18 years old. 16 successful programs
have been completed within the Cardiac
Department.
Hansen, Tulinius, Hansen 2007
“You CAN Do It”
This program is based on a series of
steps. The first being the child’s
willingness to participate. They must feel
that they are ready to learn how to
swallow pills. Next, set up the baseline.
How large of a ‘pill’ can the child swallow
without any intervention? This involves
swallowing ‘pills’ ranging from very small
to very large, larger than the child’s
actual pill size.
“You CAN Do It”
SLOW & STEADY…
The average number of steps for a successful
pill swallowing program is: 13
A slow progression leads to an
increase in confidence and lowers the
chance of anxiety and frustration
“You CAN Do It”
Wherever the child starts, they must swallow
the ‘pill’ three times to prove ability. Continue to
move through the next size up until the patient
is unable to successfully swallow. At this point
move back to the last successful swallow,
repeat, and end the session. Each session
must always start and end with a successful
swallow. This will reinforce all the hard work
that was done by the child and ensure
continued practice and eventual mastery.
“You CAN Do It”
First step of pill
swallowing
program in
comparison to
goal size
Last step of pill
swallowing
program in
comparison to
goal size
Successful Pill Swallowing Using
Head Posture Variations
Four systemic studies at the Alberta Children’s
Hospital under the direction of Dr. Bonnie
Kaplan, demonstrated that practice with head
posture variations was more successful than
standard behavioral approaches in treating pill
swallowing difficulties. One study stated that,
“practice with head posture variations were
successful in treating pill swallowing difficulties
in all 33 children, 2-17 years old, who practiced
for 14 days”.
Paediatric Child Health Vol 15 No 5 May/June2010
Successful Pill Swallowing in
Using Head Posture Variations
 This
technigue is also referred to as “The
Method of Off Centre Swallowing”. It
requires 30 minutes to learn followed by 2
weeks of practice, 5 minutes a day, with
candy.
 There
is evidence that different head
positions makes it easier to swallow pills.
Successful Pill Swallowing Using
Head Posture Variations
 The
traditional psychological principles
used to engage the children are
reassurance, education and the use of
candies
 The only ‘active’ component of this
intervention is head posture and practice
 This technique does not rely on
conventional behavioural techniques such
as stimulus shaping, positive
reinforcement and relaxation
Successful Pill Swallowing Using
Head Posture Variations
Introducing the program:
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Determine the child’s willingness and
ability to learn and practice
Provide reassurance
Adopt a playful attitude
Using a diagram provide a simple
explanation of the esophagus, comparing
it to the size of a ‘pill’, and describing it’s
flexibility
Successful Pill Swallowing Using
Head Posture Variations
Teach the ‘ngunk’ noise that their throats make
when they swallow with their heads turned off
centre. When you turn off centre there is a
spasm in the esophagus that opens the throat
wider
 Most children determine a preference other than
centre forward
 Teach the ‘duck shake’ that will help position the
‘pill’Teach the head postures (centre, up, down,
left and right)
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Successful Pill Swallowing Using
Head Posture Variations
 First
try with water
 Assume correct posture with shoulders back
 Place a candy on the back of the tongue
 Take a small sip of water
 Do the ‘duck shake’
 Assume head position
 Swallow and record self assessment in each of
the 5 positions
 Assign homework – I candy in each position - 5
minutes a day for 14 days
 Evaluation/Outcome
“Better Than A Spoonful of Sugar”
Video
References and Discussion
Behaviour Modification What It Is and How to Do It
Garry Martin and Joseph Pear 2007
Internet Sites:
Breaking Down the Barriers of Pill Swallowing
Through Behaviour Modification “You CAN do It” Pill
Swallowing Program Alison Pummel, Child Life
Specialist, The Hospital for Sick Kids, Child Life
Council 27th Annual Conference on Professional
Issues
Better than a Spoonful of Sugar-How to Swallow Pills
Bonnie Kaplan, Behavioural Research Psychologist,
Alberta Children’s Hospital